Introduction

With today's intensified focus on patient centered and culturally competent care, it is important to acknowledge the needs of populations that may live a more marginalized life. While the transgender community is gaining visibility and acceptance in the overall population, barriers still exist in their seeking of health care. In a recent survey-based study of over 6000 transgender respondents, 19% had been refused medical care, 25% delayed seeking medical care, 28% postponed needed medical care when sick or injured, and 33% delayed or did not seek preventative care as a result of previous experiences of discrimination or disrespect. Perhaps the most concerning of these findings, 2% of respondents reported having been physically assaulted in a doctor's office or hospital.1

It is clearly identified within the existing literature that fear of mistreatment and discrimination is an ongoing concern among the transgender community. It is this fear that has historically led the transgender individual to avoid seeking needed care.2-6 This avoidance of the healthcare system is only part of a multifactorial environment of marginalization that can lead to health disparities among this population.7

Transgender is an umbrella term used to describe individuals whose gender identity differs from society's male/female binary understanding of gender and their birth or assigned sex. For example, the transgender man is assigned the female sex at birth, yet he identifies as male on the spectrum of gender identity. As the transgender population becomes more visible and vocal, more individuals are finding the courage to identify themselves as transgender. This has led to more accurate estimations of the size of the population. In 2016, a Williams Institute survey found that an estimated 0.6% or 1.4 million people in the United States identified as transgender. This number is double that of prior estimates.8 In 2016, Winter et al. investigated international studies to estimate the global prevalence of the transgender population. They found studies indicating that the prevalence of persons who identified as transgender was 0.5% in the United States and the United Kingdom, 0.6% in Belgium, 0.9% in the Netherlands and 1.2% in New Zealand.9 As knowledge about the size of the transgender population improves, there is a growing urgency to focus on recognizing and eliminating the barriers to care that continue to exist.

Transgender men face challenges and barriers when seeking health care. When female reproductive organs and genitalia are retained, transgender men will need to access reproductive and gynecological health care and screening examinations. If routine screening exminations are neglected, transgender men may face health risks or may be forced to access emergency care for gynecological concerns. Transgender men may also select to conceive and bear children and would need to access both fertility resources, and labor and delivery services. Of concern, transgender individuals frequently point to unnecessary genital examinations by providers as a reason for avoiding medical care.1-3,10-13 The reality that these types of examinations are often needed also prompts many transgender men to avoid preventative care as a result of past discrimination.14-18 When transgender men do seek preventative care, they must often contend with a provider and staff who are both poorly educated and ill prepared to care for such a specialized clientele.5,19-22

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports was conducted, and no current or in-process systematic reviews on the topic were identified.

To identify if adequate evidence is available on the topic of interest, a preliminary search of the CINAHL database was conducted in September of 2018. This limited search revealed several existing reports of qualitative research on this topic.

Studies identified during this preliminary search revealed qualitative research that focused on several different aspects of the phenomenon of interest. Hoffkling et al.,23 Wingo et al.18 and Armuand et al.24 discussed the experiences of transgender men and pregnancy as well as fertility preservation. Hoffkling et al. described themes that included a lack of biomedical information and provider training, lack of cultural competency, transphobia, inappropriate medical care and institutional erasure as related to transgender men and pregnancy. Armuand et al. focused their research on the experiences of transgender men around the fertility preservation process in Sweden. Key findings of their research included concerns around genital examinations as well as fertility preservation techniques. MacDonald et al.25 investigated the experiences of Canadian transgender men with lactation, chestfeeding and gender identity. A key finding of their research included discomfort with discussing pregnancy and chestfeeding with their chest masculinization surgeons. Another focus identified in the preliminary search revolved around cervical cancer screening and transgender man. Johnson et al.15 qualitatively explored the cervical cancer screening experiences of sexual minorities assigned female at birth and include four female to male participants.

Several other studies found during this preliminary search focus less specifically on transgender men and reproductive healthcare experiences. Chisolm-Straker et al. explored the experiences of transgender and gender nonconforming individuals in seeking emergency care.11 While this is not specific to a gynecological setting, several findings within this study refer to transgender men who have received gynecological or obstetric care in the emergency setting. Lindroth et al. qualitatively explored the experiences of transgender persons in meeting sexual health care professionals in Sweden.26 Key findings of their research included experiences of transgender men around sexual health. In an Australian national survey published by Jones et al., experiences of female to male transgender persons were explored, and several of the findings focused on gynecological or reproductive care.27

The key findings of these identified studies will be explored more in-depth in the proposed systematic review. Based on the results of this limited search, however, it is believed that there is sufficient global research available for the conduct of this systematic review.

Compassionate, culturally competent care requires an in-depth understanding of the special needs of the transgender individual. This understanding can be gained through listening to the voices of those experiencing care as it exists today. The objective of this review is to gain further understanding of the experiences of transgender men when seeking gynecological and reproductive healthcare in both the community and acute care settings. The ultimate aim of this review is that frontline clinicians and policy makers will use the knowledge to inform and impact care experiences for transgender men seeking care locally as well as globally.

Review question

What are the experiences of transgender men in seeking gynecological, fertility and/or reproductive healthcare in all healthcare settings globally?

Inclusion criteria

Participants

The review will consider all studies that include natal females who identify as transgender men, gender non-binary, gender expressive or gender queer. Puberty may necessitate gaining access to gynecological care for the first time. On average, natal females experience menarche between 12 and14 years of age.28 In an attempt to gain understanding of these experiences, an age range of 12 years through adulthood has been selected.

Phenomena of interest

This review will consider studies that explore the experiences of transgender men seeking gynecological care, obstetrical care, fertility care or reproductive care.

Context

This review will consider qualitative studies that explore those experiences with care that take place in clinics, physician offices, emergency departments (if seeking care for gynecological conditions), and obstetrical labor and delivery units of hospitals.

Types of studies

This review will include studies that draw on the experiences of transgender men while seeking gynecological, reproductive or fertility related care in which researchers have collected and analyzed qualitative data, including but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

Methods

The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.29

Search strategy

The search strategy aims to locate both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL will be undertaken followed by an analysis and of the text words obtained in the title and abstract, and the index terms used to describe the articles. A second search using all identified keywords and index terms will be undertaken across all included databases. Third, the reference lists of all identified reports and articles will be searched for additional studies. A full search strategy will be detailed in the appendix of the final report of the planned systematic review. An example of a preliminary draft search conducted in CINAHL is shown in Appendix I. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. Truncation and wild cards will be utilized to ensure international and regional differences in spelling for search terms are captured in the search results. A nursing library scientist will be consulted throughout the search phase of the planned review to ensure the best possible results are identified.

Studies published in English will be included. Studies published from 1979 to the present will be included as 1979 was the year of the first publication of the World Professional Association of Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (formerly the Benjamin Standards of Care).30

Information sources

The databases to be searched include: CINAHL Complete (EBSCO), PubMed, PsycINFO (EBSCO), PsycArticles (EBSCO), Science Direct All Subscribed Content (Elsevier) and Web of Science. Sources of unpublished studies and gray literature to be searched include: Google Scholar, MedNar and ProQuest Dissertations and Theses.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote (Clarivate Analytics, PA, USA) via Web of Science access and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review report. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final systematic review report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.31

Assessment of methodological quality

Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Assessment and Review instrument contained and accessed via JBI SUMARI.32 Authors of papers will be contacted to request missing or additional data for clarification, where required. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible). The results of critical appraisal will be reported in narrative form and in a table.

Data extraction

Qualitative data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool.32 The data extracted will include specific details about the populations, context, culture, geographical location, study methods and phenomena of interest relevant to the review objective. Findings and their illustrations will be extracted and assigned a level of credibility. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data synthesis

Qualitative research findings will, where possible, be pooled using the meta-aggregation approach.33 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.33 The Summary of Findings will include the major elements of the review and detail how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest and context for the review. Each synthesized finding from the review will then be presented, along with the type of research informing it, a score for dependability and credibility, and the overall ConQual score.

Appendix I: Search strategy for CINAHL (EBSCO)

References